Basic Information
| Provider Information | |||||||||
| NPI: | 1104881176 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1725 W HARRISON ST STE 710 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606123863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129423034 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1725 W HARRISON ST STE 710 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129423034 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 03/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2088P0231X | 036-110209 | IL | N | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology | 208800000X | 036-110209 | IL | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 0015632900004 | 05 | PA | MEDICAID | 0892066 | 05 | OH | MEDICAID | 423827 | 01 | OH | WELLCARE | OTHER | P00829965 | 01 | OH | MEDICARE RAILROAD | OTHER |